Decision Report 201900286

Summary

C complained that the care and treatment they received from the board was unreasonable. C was added to the general surgery waiting list for gallbladder removal via keyhole surgery. The board determined that C would require an Intensive Care Unit (ICU) bed booked for the time of surgery, in case the operation needed to be converted to open surgery. C waited several months for surgery, and the board stated that this was due to a high level of demand for hospital services, including ICU beds. C eventually underwent surgery but did not improve postoperatively and developed a wound abscess (a painful swelling caused by a build-up of pus) and sepsis (blood infection). The abscess was drained, and C was treated with antibiotics. C raised concerns that there were unreasonable delays to their initial surgery, which allowed their condition to deteriorate. C also complained that there was not enough care taken during their two surgeries and they developed sepsis, which they considered could have been avoided.

We took independent advice from a consultant general surgeon and a nurse. We found that the sequence of events, the management of C's booking for surgery, the preoperative assessment, C's medical state, and the anaesthetic view did not support the board's statement that the delay in C's operation was due to lack of ICU beds. In addition, we found that the board failed to meet the Treatment Time Guarantee in C's case and to properly advise them of this under the relevant regulations. We considered that the delays C experienced were unreasonable.

With regard to C's surgery and postoperative infection, we found that the initial surgery and the surgery to drain their abscess was carried out appropriately. The diagnosis and management of their sepsis postoperatively was also reasonable. However, we found that there was a lack of documentation to demonstrate that medical staff discussed C's condition and management with either C or C's partner and this was unreasonable. As a result, we upheld C's complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients who have been admitted as an emergency, as in C's case, and require to be seen in an out-patient clinic for clinical assessment prior to surgery should receive a timely appointment.
• The board should take all reasonably practical steps to manage patients scheduled for gallbladder surgery without delay and in line with the Treatment Time Guarantee with appropriate assessment of risk for ICU beds.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.